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Forms

The forms below are commonly used by Boeing members and providers. If you don't find the form you need, contact Boeing Member Services at 888-802-8776.

Unless otherwise noted on the form, please send completed forms with any required documentation to:

Blue Cross and Blue Shield of Illinois
P.O. Box 805107
Chicago, IL 60680-4112

Member claim submissions can also be made via secured message in the Message Center by logging into Blue Access for MembersSM.

Member Forms

Coordination of Benefits Questionnaire
If you or your dependents are covered under more than one medical plan, the plans will work together to coordinate the benefits you receive. To determine if Coordination of Benefits is available and appropriate, Blue Cross and Blue Shield of Illinois may ask you to complete the Coordination of Benefits Questionnaire.

Disabled Dependent
Use this form to certify disabled dependent status. To help ensure benefits are administered in accordance with your Boeing health care benefit plan, your plan requires annual recertification. Please be sure to complete the Disabled Dependent Form in its entirety, including the accompanying Physician Certification section on the second page.

Medical Claim (Domestic)
Use this claim form to request reimbursement for applicable medical expenses incurred for services not directly billed to the plan.

Medical Claim Form (International)
Use this Blue Cross Blue Shield Global Core International Medical Claim form to request reimbursement for applicable medical expenses incurred internationally for services not directly billed to the plan.

Prescription Drug Claim Form
Use this claim form to request reimbursement for applicable prescription drug expenses incurred for services not directly billed to the plan.

Standard Authorization to Use or Disclose Protected Health Information (PHI)
Complete and submit this form to allow the disclosure of your Personal Health Information (PHI) to any specific person or entity.

Provider Forms

Applied Behavior Analysis (ABA) Clinical Service Request Form
This request will need to be completed for the first Applied Behavior Analysis (ABA) session along with the Member Treatment Schedule.

Applied Behavior Analysis (ABA) Initial Assessment Request Form
This request will need to be completed for ongoing ABA sessions along with the Member Treatment Schedule. This form is to be used after the initial form and initial visit have been completed.

Clinical Update
If a member has been selected to be a part of the Focused Outpatient Management Program, this form is to be completed by the outpatient therapist or prescribing provider.

Coordination of Care
This request is to provide member treatment information to another treating provider or request member treatment information from another treating provider. This form is available as an option but providers may use their own Coordination of Care Form if they choose.

Electroconvulsive Therapy (ECT) Request
This request is for a clinical review if Electroconvulsive Therapy meets the medical necessity definition under the member's benefit health plan.

Intensive Outpatient Program (IOP) Request
This request is for a clinical review if the Intensive Outpatient Program treatment meets the medical necessity definition under the member's health benefit plan.

Predetermination Form
This request is for verification of benefits, prior to rendering services, that may be considered experimental, investigational, or cosmetic. Approvals and denials are based on approved Medical Policies.

Psychological/Neuropsychological Testing Request
This request is for a clinical review if Psychological or Neuropsychological testing meets the medical necessity definition under the member's benefit health plan.

Repetitive Transcranial Magnetic Stimulation
This request is for a clinical review if Repetitive Transcranial Magnetic Stimulation meets the medical necessity under the member's health benefit plan.